Intended for healthcare professionals

Practice Practice Pointer

Advising patients with existing conditions about fasting during Ramadan

BMJ 2022; 376 doi: https://doi.org/10.1136/bmj-2020-063613 (Published 31 January 2022) Cite this as: BMJ 2022;376:e063613
  1. Ammad Mahmood, clinical research fellow in stroke and neurology registrar1,
  2. Sahira Dar, general practitioner2,
  3. Ammarah Dabhad, clinical pharmacist3,
  4. Bilal Aksi, patient4,
  5. Tahseen A Chowdhury, consultant physician and diabetologist5
  1. 1Institute of Neurosciences and Psychology, University of Glasgow, Imaging Centre of Excellence, Queen Elizabeth University Hospital, Glasgow
  2. 2NHS Greater Glasgow and Clyde Primary Care Division, Glasgow
  3. 3Royal Wolverhampton NHS Trust, Wolverhampton, UK
  4. 4Glasgow
  5. 5Royal London Hospital, London, UK
  1. Corresponding: A Mahmood ammad.mahmood{at}glasgow.ac.uk

What you need to know

  • Identify potential harms (such as from medication incompatibility or expected metabolic changes) that may occur with Ramadan fasting and consider mitigating measures (such as changes to medication or fasting in winter months instead of summer) or abstention from fasting

  • Seek specialist input for patients:

    • Taking specialist prescribed medications

    • With reduced life expectancy

    • Undergoing oncological treatment

    • When there is any uncertainty

  • Make shared decisions about whether to fast, safe options for administration of medicines, reduction of dehydration risk, and what constitutes adequate nutrition

  • If deterioration, disease exacerbation, or delayed recovery occurs during fasting, advise patients to break their fast, take a break from fasting, and seek medical help

Managing chronic conditions during the Islamic month of Ramadan can be challenging, especially as many patients may prioritise fasting over health concerns.123 For example, one epidemiological study of 13 countries with large Muslim populations in Asia, northern Africa, and the Middle East showed increased hypoglycaemic episodes in people with diabetes (types 1 and 2).1 Also challenging is when Ramadan occurs close to the summer solstice in regions at extremes of latitude (when daylight hours are longer), in both hemispheres.

Pre-Ramadan consultations with patients wishing to fast who have existing conditions—ideally held one to four months before the start of Ramadan—are advocated by the British Islamic Medical Association, the International Diabetes Federation, and the Diabetes and Ramadan Alliance, among others.234567

Healthcare professional opinion is pivotal—with it, Islamic authorities (such as imams and scholars) can offer further advice or assurance to patients about religious exemption from fasting.

What will this article cover?

This article describes which patients might benefit from pre-Ramadan consultations (box 1), what to ask and review during consultations, and suggestions for risk stratification and joint decision making. It is aimed at healthcare professionals including GPs, specialist doctors, specialist nurses, midwives, and pharmacists.

Box 1

Which patients might need or request a pre-Ramadan consultation?

Patients with chronic physical health conditions

Although fasting has been shown to improve fatigue, mood, and quality of life in people with and without chronic health conditions and may play a role in the spiritual care of people with advanced disease, adjustment of drug regimens may be necessary in many conditions including adrenal insufficiency, thyroid disease, diabetes, and cancer.18910111213

Patients with mental health conditions

A systematic review concluded that fasting is safe for most conditions other than schizophrenia and bipolar disorder, where evidence was conflicting as to whether symptoms were improved or worsened by fasting.14 People with eating disorders might also be at risk from disruption to their usual eating patterns.15

Patients who are pregnant

Observational studies of pregnant women suggest that the numbers of pregnant Muslim women who choose to fast for at least some of the month can be up to 90%.1617 Factors such as medical history, any pregnancy complication, medication, length of daily fast, and risk of dehydration (such as from hyperemesis gravidarum) can help identify higher risk cases.

A systematic review and meta-analysis suggests that Ramadan fasting does not cause reduced birth weight or increase the risk of preterm delivery, but placental weight is lower in fasting mothers.18 Evidence is lacking for other outcomes (such as perinatal mortality and longer term development).18192021

Patients who are breastfeeding

Clinical evidence is limited. A descriptive cross-sectional questionnaire study suggests up to 90% of breastfeeding patients may fast during Ramadan.22 A review of observational studies comparing lactation in Yom Kippur/Ninth of Av and Ramadan found electrolyte changes during Ramadan to be “moderate but not clinically relevant” and “almost no changes in macronutrients (lactose, protein, fat, solids, triglycerides, cholesterol).”23

People in certain occupations

For example, the risk of hypoglycaemia in diabetes or breakthrough seizures in epilepsy, can be amplified in those who operate heavy machinery or drive in their occupation.624

For healthcare professionals struggling to tolerate fasting with PPE during the covid pandemic, occupational health specialists in the UK and Saudi Arabia recommend reassignment or, if issues of staffing and patient safety make reassignment unfeasible, termination of fasting with the option to make up fasts at a later date.25

RETURN TO TEXT

The main religious reference used is a textbook of Islamic guidance from the Hanafi school of Islamic jurisprudence (globally, the most practised school among Sunni Muslims).2627 Unless stated otherwise, the religious aspects of this paper are generalisable to the other mainstream branches of Sunni Islam. The clinical concepts discussed can apply to all branches of Sunni and Shia Islam. For further guidance on the religious aspects of Shia Islam, patients and clinicians can refer to Shia authorities.28

Box 2 explains the concept of Ramadan fasting and answers other questions about Ramadan.

Box 2

Explanation of Ramadan, according to the main branches of Sunni Islam2629

What is Ramadan and when does it take place?

  • Ramadan is the name of the ninth lunar month in the Islamic calendar

  • During Ramadan, many Muslims practise fasting (“sawm”)—abstention from oral intake during daylight hours—which is one of the five pillars of Islam

  • This can involve fasting for up to 30 consecutive days

  • In 2022, Ramadan is during most of April and the beginning of May

  • Ramadan is based on the lunar cycle and thus shifts through the seasons, shifting back 11 days each calendar year

  • In regions at the extremes of latitude, the amount of daylight hours (the number of daily fasting hours) can be up to 20 hours in summer and 10 hours in winter

Why do Muslims fast, especially if there are health concerns?

  • Ramadan is a time of heightened spirituality and community cohesion which Muslim patients can be reluctant to miss

  • Although Islamic guidance is meant to pre-empt and avoid threats to health, the enthusiasm of individuals to fast and partake in rituals can surpass their concerns about health

  • Globally, Muslims observe Ramadan more widely than their other religious commitments

Who does not have to fast in Ramadan?

  • Prepubertal children

  • Frail and older people for whom there is risk of harm

  • Pregnant patients if there is risk to either mother or fetus

  • Breastfeeding patients if there is threat to milk supply or infant health

  • Menstruating women and women experiencing lochia

  • People undertaking long journeys (commonly accepted as journeys >48 miles (77 km) while remaining in one place no longer than 15 days)

  • People with illnesses that would be exacerbated by fasting (generally when fasting could either worsen an existing condition to the extent that the person is weak, with reduced levels of physical activity, or is likely to cause deterioration or delayed recovery). This is determined either through prior experience or from healthcare professionals’ input

  • People with psychiatric illness or cognitive impairment who have difficulty appreciating any risk associated with fasting, and thus lack capacity for the decision

What breaks the fast?

  • Eating, drinking, smoking, or sexual activity during daylight hours

  • Certain routes for medication (see box 3)

What options are there for people unable to fast during Ramadan?

  • Conducting fasts at a later date if or when they are able (“qada”)

  • Extra prayers and reading of the Quran

  • Charity (“fidyah”)

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Box 3

Summary of differing Sunni Islamic opinion regarding medication routes*3839

  • All agree not allowed—Oral, rectal, nasogastric†

  • Majority agree not allowed—Inhaled, intravenous

  • All agree allowed—Topical, intramuscular, subcutaneous

  • Majority agree allowed—Eye, ear

  • *Guidance about more specialist medication administration (such as intraperitoneal administration of antibiotics or insulin for patients on dialysis) is not included

  • † Nasal and buccal may be allowed if there is no risk of passage into the throat and beyond

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What is the evidence?

The advice in this article is based on our collective experience of advising patients during Ramadan and our familiarity with Islamic guidance and practices. We were unable to find any published data on pre-Ramadan consultations or how widely they are carried out in various regions.

There is also little information on the natural course of most conditions in a fasting state. The literature that exists predominantly concerns diabetes,530 but there is also guidance on cardiac disease,31 epilepsy,6 kidney disease,32 adrenal disease,33 occupational health,25 and conditions presenting to general practice.34 Further condition-specific data are emerging and mostly consist of single publications dealing with specific issues, local hospital or health board guidelines, or specialist opinion. Detailing condition-specific criteria is beyond the scope of this article, but we have included clinical examples and condition-specific resources.

What is reviewed during the consultation?

The factors discussed in this section are also summarised in the infographic.

In our experience, consultations three to four months before Ramadan can allow for implementation of changes to lifestyle and medication where required. Consultations closer to Ramadan can still be helpful and may be necessary if there are changes in a patient’s health or preferences. Consider annual alerts in clinics or practices to trigger review of patients known to fast who have existing medical conditions. The format and content of each consultation will vary. Below is a summary of what might be covered.

Personal preferences, priorities, concerns, and beliefs

As with all religions, opinion varies about the definitions and understanding of what is compulsory and what is not, and personal motivation to fast may be higher in some than others. There will also be variation in health beliefs,35 understanding of health issues, appreciation of risks, and knowledge of fasting or fast-breaking strategies.

Climate, length of daily fasts, and intended dietary and lifestyle changes during the fasting period

Depending on the time of year and geographic location, the period of night-time food and fluid consumption will range from four to 14 hours. Diet, sleep patterns, and routines are dramatically altered to accommodate night-time meals, social gathering, and late night prayers.3637 Disruption of regular sleep patterns, for example, may lead to increased seizures in people with epilepsy.6

Dehydration poses a risk in several conditions, particularly when patients are fasting in hot climates or when lengths of fasts are over 20 hours.

Current pregnancy, breastfeeding, and occupation status, and working patterns

See boxes 1 and 2.

Medical history

This allows individualised risk evaluation and consideration of comorbidity (the compound risk with multiple conditions is higher than the risks of individual conditions).

Previous fasting experiences

Patients’ experience of fasting with their condition(s) can be the most informative factor. For example, fasting consecutively for an entire month may be known, from previous years, to cause deterioration or additional morbidity; or previous fasting without deterioration or additional morbidity might support a decision to fast or to follow a particular regimen of medication.

When a diagnosis or condition is new since the previous Ramadan, or circumstances have changed, we recommend trial fasts (see box 4).

Box 4

Trial fasts

Benefits

  • To evaluate individualised risks, especially if

    • A condition is new since the previous Ramadan

    • Circumstances or condition severity have changed

    • There have been medication changes

    • Medication change may be required during Ramadan

  • To assess risk of dehydration and adequacy of nutritional changes

  • To allow acclimatisation

  • To assess whether fasting causes complications (such as loss of diabetic control, uncontrolled hypertension, breakthrough seizures, etc) and to therefore fine-tune changes to medication or decide that fasting is too high a risk

Advice for conducting trial fasts

  • Be adaptable

  • Patients might want specific instruction, such as the number of days they should perform trial fasts

    • There is no supporting literature, but in our experience three to five “practice fasts” in the month before Ramadan (when fasting hours are similar) or, in higher risk cases, during shorter winter fasting days, is helpful. These could be consecutive days or, if risk is higher, non-consecutive

  • Consider asking patients to document their trial fasts: what they ate, timings, etc

  • Patients may be more willing to terminate trial fasts than Ramadan fasts if difficulty occurs

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Medication history

  • Focus on prescribed medications and timings of doses. Give specific consideration to drugs that can cause dehydration (such as diuretics) or hypoglycaemia (such as gliclazide or insulin) and drugs that can be sensitive to alteration in regimens such as antiepileptics.

  • Ask about over-the-counter or complementary medications.

  • Consider whether intended dietary changes during Ramadan may affect drug interactions.

  • Review administration routes: different branches of Sunni Islam have different thoughts on which routes are permissible during fasting hours (see box 3).3839

How can risk be stratified?

Determine individual risk

We advocate stratifying the risk of deterioration, disease exacerbation, or delayed recovery into three tiers, as per the 2017 guidance from the international DAR-IDF collaboration, which issues advice on fasting for people with diabetes (box 5 and infographic).

Box 5

Stratification of risk of deterioration, disease exacerbation, or delayed recovery during fasting, as per the 2017 guidance from the international DAR-IDF collaboration2

Very high risk

Advise strongly against fasting. If patient chooses to fast, seek opinion of a religious authority to discuss religious exemption from fasting

Examples*

  • Advanced heart failure (LVEF <35%, NYHA III-IV)31

  • Poorly controlled type 1 diabetes or insulin treated type 2 diabetes with no prior experience of fasting25

  • Chronic kidney disease stage 4-532

  • Pregnancy with poorly controlled diabetes, blood pressure, or epilepsy267

High risk

Advise against fasting. If patient chooses to fast, advise caution

Examples*

  • Myocardial infarction within the preceding six months31

  • Well controlled type 1 diabetes or insulin treated type 2 diabetes with prior fasting experience, or type 2 diabetes and pregnancy25

  • Chronic kidney disease stage 332

  • Epilepsy requiring treatment regimen incompatible with fasting hours and cannot be safely adapted6

Moderate to low risk†

Advise that patients may fast if medication and lifestyle issues addressed

Examples*

  • Hypertension31

  • Stable angina31

  • History of stroke or other neurological disability (such as multiple sclerosis) with minor disability4041

  • Well controlled epilepsy on a single medication6

  • Migraine7

  • DAR = Diabetes and Ramadan. IDF = International Diabetes Federation. NYHA = New York Heart Association (NYHA) Functional Classification.

  • *This is not a full list of conditions. For further resources about specific and more specialist conditions, see box 6.

  • †The presence of multiple moderate/low risk conditions may prompt a decision to move up a tier during risk stratification.2

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Box 6

Further resources for specific specialties

  • Adrenal—Hussain S, Hussain S, Mohammed R, Meeran K, Ghouri N. Fasting with adrenal insufficiency: Practical guidance for healthcare professionals managing patients on steroids during Ramadan. Clin Endocrinol 2020;93:87-96.

  • Cardiology—Akhtar AM, Ghouri N, Chahal CAA, et al. Ramadan fasting: recommendations for patients with cardiovascular disease. Heart 2021:heartjnl-2021-319273

  • Diabetes—IDF-DAR Practical Guidelines 2021. Diabetes and Ramadan. www.daralliance.org/daralliance/idf-dar-practical-guidelines-2021

  • Epilepsy—Mahmood A, Abbasi HN, Ghouri N, Mohammed R, Leach JP. Managing epilepsy in Ramadan: guidance for healthcare providers and patients. Epilepsy & Behavior 2020;111:107117

  • Nutrition and hydration—British Nutrition Foundation. A healthy Ramadan. https://www.nutrition.org.uk/putting-it-into-practice/food-seasons-and-celebrations/a-healthy-ramadan/

  • Ramadan— Muslim Council of Britain. #SafeRamadan 2021 guidance. https://mcb.org.uk/resources/ramadan/

  • Renal—Malik S, Bhanji A, Abuleiss H, et al. Effects of fasting on patients with chronic kidney disease during Ramadan and practical guidance for healthcare professionals. Clin Kidney J 2021;14:1524-34

  • Various—British Islamic Medical Association. Ramadan compendium. https://britishima.org/ramadan/compendium/

RETURN TO TEXT

The examples in box 5 are provided only as a guide; consider patients on a case by case basis. Judgment of risk can also be based on the factors summarised in the infographic. The presence of multi-morbidity, for example, may prompt consideration of higher risk than that of each condition in isolation. In 2021 the updated DAR alliance guidelines switched to a points based scoring system,3 but this has been criticised for not being person-centred and focusing on a binary outcome rather than a more nuanced decision,42 leading us to remain using and recommending the established three tier system.

Seek specialist advice when there is uncertainty about risk, for patients taking specialist prescribed medications, and for those with shorter life expectancy or undergoing oncological treatment. For example:

  • Fetal, maternal, and diabetes specialists who have contributed to and reviewed this article highlighted that maternal hypoglycaemia and ketosis in pregnant patients with type 1 diabetes can harm both mother and fetus, particularly in the presence of hyperemesis and when fasts are >12 hours. Oral intake of fluid and food can avoid this risk. They say that treatment goals for type 2 and gestational diabetes include spacing of meals and reduction of portion sizes, which may be incompatible with Ramadan fasting. They advise that type 1 diabetes in pregnancy is always considered as very high risk and that type 2 and gestational diabetes as moderate to high risk, but potentially very high risk if hyperemesis gravidarum is present.237

  • Although chronic kidney disease stage 3 is listed as high risk in box 5, specialist reviewers highlight that, under conditions of little or no proteinuria, well controlled blood pressure, and a stable and well preserved glomerular filtration rate, could be considered as lower risk. It is therefore important that specialist opinion is sought.

  • Specialist reviewers highlight that heart failure staging as indicated in box 5 could be considered as lower risk when specialist opinion is sought.

How are shared decisions made?

Bringing together patient opinion and healthcare professional advice (evidence based when possible) increases engagement, comprehension, and understanding of management options and related consequences.434445 By stratifying risk into very high, high, and moderate to low, we believe decisions are easier to make.

About lifestyle and work

  • For example, advise patients with epilepsy about adequate regular sleep during Ramadan.6

  • Advise patients to communicate with employers about shift pattern work or risk of dehydration in manual labour, particularly in hot climates or working conditions where temporary reassignment may be required.46

About nutrition and hydration

  • The British Nutrition Foundation recommends eating balanced meals including wholegrains, fruits and vegetables, dairy foods, and protein-rich foods during non-fasting hours.47

  • People with eating disorders may require closer monitoring.15

  • Encourage consumption of 2.5-3 litres of fluids during non-fasting hours: even with longer fasts, avoid taking >3 litres due to fluid overload and hyponatraemia risks.

About medication changes

  • Short term medication changes can affect patients’ long term health. Always seek specialist input for specialist-managed conditions. In many cases, lower risk drugs (such as analgesia) may be switched without specialist input (such as conversion to patch formulations). Patients can guide healthcare professionals regarding which administration routes they consider acceptable (see box 3).

  • Alternative drugs or modified release preparations might be considered when more than one daily dose is required and non-fasting hours are <6-8 hours.

  • Without medication adjustments, risk-free fasting may not be possible.

  • Medication might be taken before the fast begins (at suhoor) or when the fast ends (at iftar).

  • Advise patients to refrain from fasting if they are sensitive to medication changes or if medication is required throughout the day and there is no suitable alternative.

  • Advise patients to refrain from fasting if set dose timings cannot be altered, such as high dose (>300 mg total daily dose) levodopa in Parkinson’s disease.48

  • Consider whether altered intake of food during Ramadan may affect drug pharmacodynamics (such as with warfarin, thyroxine, oral bisphosphonates, and certain antibiotics).

Comprehensive, condition-specific recommendations are beyond the scope of this article, but table 1 summarises specialist advice for adjustment of more commonly prescribed medication, and box 5 lists further specialist resources.

Table 1

Specialist-led medication adjustment that might be considered during Ramadan for commonly prescribed drugs26484950515253

View this table:

About fasting against medical advice

If patients wish to fast despite a high medical risk:

  • Discuss condition-specific safety measures and red flags to be aware of

    • Advise to immediately break the fast and seek medical help if health deteriorates acutely

  • Offer support with medication, diet, fluid intake, and lifestyle

  • Consider specialist consultation

  • Document that medical advice was given but patient choice was respected

  • Inform other healthcare professional teams involved in the patient’s care

  • Reassure patients that Islamic guidance permits the termination of fasts for medical reasons (acute and chronic); if doubts remain, patients can consider consulting religious authorities.

About alternatives to fasting

  • People may partake in the non-fasting elements of Ramadan, which is also a time of charity, spirituality, and communal prayers.

  • If the length of a summer fast is the prohibitive factor, then patients can switch to fasting during winter months54

  • If disease exacerbation might occur, consider non-consecutive fasts (such as alternate days or a one day break after every two to four fasts).55

Case studies

Acute illness

  • Background—42 year old woman with no prior medical history develops fever and cough and tests positive for covid-19

  • Risk—Fasting may worsen illness and delay recovery

  • Recommendation—Stop fasting while she has symptoms. Once recovered, her fasts can be made up after Ramadan

  • Note—Other common respiratory illnesses may not preclude fasting if they are mild

Managing lifestyle factors

  • Background—59 year old man with hypertension and stage 2 chronic kidney disease taking ramipril and amlodipine

  • Risk—Moderate to low

  • Recommendation—Can fast, but encourage to drink 2.5-3 L of fluids during non-fasting hours. Extra care should be taken if fasts are long or in hot weather

Unable to fast

  • Background—72 year old man with history of prior myocardial infarction and chronic heart failure (NYHA III) taking aspirin, ramipril, bisoprolol, and furosemide twice daily

  • Risk—Very high due to medical history and twice daily use of diuretics

  • Recommendation—Not able to fast now or in the future. Consider fidyah in place of fasting

Summer-winter switching

  • Background—37 year old woman with well controlled epilepsy taking levetiracetam twice daily is unsuited for switching to an alternative, once daily antiepileptic

  • Risk—Moderate to low in winter, when twice daily dosing is feasible, but high in summer, when it is not

  • Recommendation—In summer, consider fasting at another time of year when twice daily dosing is possible

Fasting against advice

  • Background—35 year old woman with poorly controlled type 1 diabetes and previous diabetic ketoacidosis insists on fasting against medical advice

  • Risk—Very high, and fasting is not advisable in any setting

  • Recommendation—Involve an imam or religious scholar who can provide religious counselling. If the woman continues to fast, advise summer-winter switching and appropriate management of insulin for risk mitigation

Multiple comorbidities

  • Background—61 year old man with obesity, hypertension, stable angina, type 2 diabetes, and gout taking metformin, gliclazide, ramipril, aspirin, simvastatin, bisoprolol, and isosorbide mononitrate

  • Risk—Although each condition confers a moderate to low risk, the compound risk is elevated to high

  • Recommendation—Avoid long fasts. Shorter winter fasts may be manageable. Consider a trial of fasting and adjustment of medication

  • NYHA = New York Heart Association (NYHA) Functional Classification.

Education into practice

  • How can you reach shared decisions about safe fasting?

  • How can you support patients at high risk from fasting?

  • Would you consider discussing Ramadan with imams or other Muslim leaders in your community?

How this article was made

We based our recommendations on the available literature; our experience of advising patients during Ramadan and our familiarity with Islamic practice; specialist input from contributors (endocrinology, diabetes, maternal and fetal medicine, lactation, renal medicine, pharmacology, oncology, psychiatry, Islamic studies); and input from Muslim patients.

How patients were involved in the creation of this article

An author with experience of fasting in Ramadan with a chronic condition, made possible by quick access to medical advice, reviewed all drafts of the article and advised regarding measures patients would find helpful, in particular the approach to pre-Ramadan consultations and possibility of an alerts system for general practitioners and specialist clinics. A patient reviewer gave inputs on use of terminology, diet considerations, advice around breastfeeding, and the usefulness of practice fasting.

Footnotes

  • Contributors: AM wrote the first draft, produced the graphics, and revised the subsequent drafts. SD, AD, and TAC reviewed the drafts and contributed to the revisions. BA, the patient author, reviewed the drafts and provided feedback on areas that would be useful to patients. All authors contributed to the conceptualisation and design of the article and approved the final draft. TAC is guarantor of the overall content of the article.

  • A team of contributors was involved in the review of subsequent drafts providing advice on both the clinical and religious aspects of the paper. The contributors were:

  • • Nazim Ghouri, consultant physician in diabetes, endocrinology and general medicine, Queen Elizabeth University Hospital, Glasgow; and honorary clinical senior lecturer, University of Glasgow

  • • Zohra Ali, clinical research fellow, medical oncology (Post CCT), Royal Marsden Hospital NHS FT

  • • Asim Yusuf, consultant psychiatrist, Black Country Partnership NHS Trust; and chair of the British Board of Scholars and Imams

  • • Rafaqat Rashid, general practitioner; honorary lecturer, University of Leeds; and Islamic scholar (academic director of the Al Balagh Academy)

  • Competing interests: We have read and understood The BMJ policy on declaration of interests. The BMJ has judged that there are no disqualifying financial ties to commercial companies. The authors declare the following other interests: AM and TAC are editors of the British Islamic Medical Association Ramadan Compendium published in 2021.

  • Patient consent not required (patient anonymised, dead, or hypothetical).

  • Provenance and peer review: Commissioned, based on an idea from the author; externally peer reviewed.

References

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